Actinomyces cavernous sinus infection: a case and systematic literature review

Abstract

A 63-year-old man presented with a 2-month history of progressive right-sided exophthalmos, painful ophthalmoplegia and fevers. As more features developed, he was diagnosed with giant cell arteritis, then Tolosa-Hunt syndrome, and transiently responded to corticosteroids. A bland cerebrospinal fluid and highly metabolically active brain (F)-fluoro-D-glucose-positron emission tomography suggested lymphoma. Biopsy of the mass showed sulphur granules with Gram-positive filamentous bacteria with -like colonies. cavernous sinus infections are rare and indolent. They often mimic non-infective causes including other inflammatory and infiltrative conditions, vascular and neoplastic causes, particularly lymphoma. Clinicians should consider infective cavernous sinus syndromes in people with a fluctuating painful ophthalmoplegia that responds poorly to corticosteroids. The term Tolosa-Hunt syndrome is problematic and should be retired or used only with reservation.

Tolosa–Hunt Syndrome

“…Lubomski et al recommended retiring the term THS and instead using a simple description “PO resolving with corticosteroids” which inherently implies uncertainty and a need for careful review. 47 They favored biopsy in all cases, where a lesion is visible on imaging, unless contraindicated, to avoid delayed/misdiagnosis. Lueck proposed using the terminology “presumed granulomatous inflammation” to emphasize the need for re-evaluation of the diagnosis from time to time.…”

“… Presence of additional systemic features 26 44 45 46 47 48 49 50 51 Other neurological deficits 52 53 54 Evidence of immune suppression or previous malignancy 55 56 57 58 59 60 61 62 63 Atypical features on MRI including nonenhancement on contrast 45 51 53 63 64 65 Involvement of mandibular or maxillary division of trigeminal (THS is primarily an inflammation of anterior CS) 28 44 Failure of resolution clinically/on MRI 26 28 46 53 66 Severe vision loss. 26 …”

Prevalence of Bacteria of Genus Actinomyces in Persistent Extraradicular Lesions—Systematic Review

“…Teeth subjected to a radiographically correct endodontic retreatment [66], but with the presence of radiographic radiolucent lesion, fistula with drainage of purulent material, are suspected of persistent extraradicular infection that can evolve into a cervical facial form, characterized clinically by skin lesions with hardened area with multiple abscesses containing grainy tissue, which tend to form cavities and drain onto the skin with purulent material containing granules described as "sulfurous" (the name sulfurous derives from the yellowish coloring of the yellow bacterial filamentous aggregates) [67].…”

Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment

“…THS is essentially a pathology of exclusion therefore any patients presenting with one-sided PO without any other neurological anomaly should undergo a proper and extensive medical assessment to avoid several readmission due to misdiagnosis [9] [19] [20]. Lately, some authors rose a debate on the controversy of the term TSH attributable to its diagnostic challenges and dilemmas towards exclusion of other granulomatous presenting conditions considering that in actual clinical practice corticosteroid trial is initiated before biopsy under the umbrella of TSH impinging a risk of delayed diagnosis or misdiagnosis, therefore, proposing the retirement of the term or be reserved only for the syndromes that get resolved with treatment with no a precise diagnosis, alternatively, suggesting a term "painful ophthalmoplegia resolving with corticosteroid" to be used instead, in the same context clinicians, got reminded to repeatedly examine the diagnosis periodically [21] [22]. Furthermore, the controversy of whether to withdraw the term TSH or establishing clear diagnostic and management guidelines is the matter of future discussions.…”